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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803905
Report Date: 11/28/2023
Date Signed: 11/28/2023 03:30:55 PM


Document Has Been Signed on 11/28/2023 03:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:ARBOL RESIDENCES OF SANTA ROSAFACILITY NUMBER:
496803905
ADMINISTRATOR:BROWN, SHANNONFACILITY TYPE:
741
ADDRESS:300 FOUNTAINGROVE PARKWAYTELEPHONE:
(707) 566-8600
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:152CENSUS: 86DATE:
11/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Hanh Ta-Executive DirectorTIME COMPLETED:
03:37 PM
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Licensing Program Analyst (LPA), Alviso, conducted a case management visit, on 11/28/23 at approximately 11:00am, and met with Executive Director Hanh Ta.

LPA reviewed resident incidents reported to the Department, and obtained more information. LPA reviewed resident records regarding incidents, and interviewed staff.

No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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